00:00Hello friends, this is a case of torqued ovarian cyst.
00:06This patient has a large dermoid cyst and it got torqued and she had a severe pain in
00:14the right iliac fossa and it was inflamed and this was that much size of the ovarian
00:21cyst.
00:23So we will do the surgery that is laparoscopic ovarian cystectomy.
00:29And this is our cystic area, we should be careful.
00:35And this ovarian cyst is a large dermoid cyst, the cent is unmarried so we will keep it in
00:40the supine position, we are not using any uterine manipulator or any lithotomy position.
00:48Now we will enter for safety initially with the palmer's point and later we will transfer
00:56the telescope to the supra-amblycal area.
01:01So pneumo-pitonium is completed and now the trocar has been introduced to the palmer's
01:06point.
01:08So we will enter inside and then other ports, this we will do ipsilateral port and one contralateral
01:27also will be required to use one endobag and one supra-amblycal will be used.
01:37For later we will transfer the telescope there.
01:40So we can see here this is an ovarian cyst and due to the torsion it was completely inflamed
01:50and omentum is trying to arrest it, trying to cover it.
01:54So we have to remove the omentum from there although it is all the adhesions due to the
01:59inflammation.
02:03But these adhesions are not very mature adhesions and you can separate all the omentum from there.
02:15Once the omentum is separated after that you can do the examination of the pedicle and this
02:25is a right ovarian cyst and it was torsion because it is becoming little fragile here at this axis.
02:36It was torqued but the problem is detorsion is not possible at this moment of time because
02:43of the inflammation and the size.
02:46So this is an endobag.
02:49You can introduce an endobag that is a commercially available endobag, it is a size C endobag.
02:55And then the ovary with the cyst will be brought inside this endobag so that if any espilage
03:06happen then it should be controlled espilage.
03:12It is impossible in laparoscopy that you can 100% guarantee that there will be no contamination
03:19but controlled espilage is okay.
03:22This is aspiration needle and slowly with the suction we are aspirating initially with the
03:28needle and then with the suction the entire fatty content of the cyst is aspirated out.
03:37of course it is dermoid so you have a thick cheesy material together with the hair together with
03:50the nail or bone may be there.
03:53So aspiration needle will not aspirate everything, suction will necessary.
04:09Once the entire aspiration as much as it is possible and it is debulk as we can see if any
04:15spillage is there that spillage is going into the endobag.
04:22There may be some time septate one or two pockets in those situations you can take both
04:30pockets separately.
04:40Once it is over after that you can try to do in those cases of the torted ovarian cyst first
04:48we should try to do detorsion.
04:52So that it will be easy to do the ovarian cystectomy.
05:00Now almost all the suction is complete and here we can see at the level of the IP ligament
05:07the torsion of the ovary and tube is visible.
05:13Once it is okay then you can start doing detorsion.
05:30So now this is detorsion which we are using doing it and this is first time.
05:52Now this is second turn and here it is third detorsion and now one more.
06:14Now it is okay.
06:15This is fimbrial end of the tube what we are seeing is and now it is fine.
06:27I think one more time.
06:31One more detorsion is required and now it is okay.
06:39So after detorsion this entire cyst will be separated from the ovary.
06:43Luckily ovary was near the ovarian ligament and it was some of the ovarian tissue can be
06:50preserved otherwise in those cases you might have to do the entire ofectomy but here we
06:56are preserving some of the ovarian tissue and with the harmonic scalpel we will separate
07:02the cyst from the ovary.
07:05In those cases the traditional enucleation of the cystic wall is not possible so you have
07:13to cut the cystic wall and then you can separate the ovarian cyst from the ovary.
07:22Now this is slowly slowly with the harmonic it is separated partial ofectomy and here remaining
07:31ovary and that much even if the 40-60% of the tissue is remaining it will work.
07:39It will do some ovary and these are cortex this is fine.
07:46You can check for any bleeding and after that this entire cyst will be kept in the endobag
07:56and then we can close the purse string of the endobag.
08:12And now this endobag mouth of the endobag will be pulled into the cannula and then everything
08:19will be pulled together.
08:24This patient has previous appendicectomy done by opane so you can see some adhesion there.
08:35And now this mouth of the endobag will be taken out and then immediate lavage should be performed
08:43for any spilled content and irrigation and suction to the curl.
08:50This is the remaining ovary of the right side and multiple time irrigation and suction should
08:56be performed so that there should not be any remnant of the spilled dermoid content.
09:08Copious lavage should be done and all the fluid will be aspirated out.
09:23In those situations it is recommended by many surgeons that open the mouth of the endobag
09:30and use it as a wound protector and slowly with the ovum forceps you should take the ovary
09:37and cystic content out.
09:40And slowly by the zig-zag fashion you can take the endobag together with the ovary cysts.
09:46So we can see here this cystic wall is coming out and you can hold with one to another artery
09:52forceps and take it out.
09:55And then again final thorough lavage will be performed.
10:00So that there should not be any residual dermoid content.
10:06So this way sometime if the dermoid cyst is ignored there may be torsion that is an emergency condition
10:14and it has a lot of you know the pain you can see on the right side of the bladder and
10:21the right side of the medial umbilical ligament still there are inflammation because at this
10:28area was completely adhered.
10:31So posterior cul-de-sac, anterior cul-de-sac and again proper irrigation and suction and
10:37thorough lavage will be performed.
10:40Any drain was not required in this case because there was no any bleeding and everything is
10:44fine.
10:46So thank you very much for watching this video, this was a simple case of torted ovarian dermoid.
10:53So thank you very much.
11:00Thank you very much.
11:09And thank you very much for joining us today.
11:12Thank you very much.
Comments